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   Table of Contents - Current issue
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September-December 2019
Volume 8 | Issue 3
Page Nos. 127-196

Online since Monday, December 9, 2019

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REVIEW ARTICLE  

The economics of healthcare personnel shortage on the healthcare delivery services in the United Kingdom versus the Gulf Cooperation Council Highly accessed article p. 127
Narendra Kumar, Shaimaa Mustafa, Cyril James, Manish Barman
DOI:10.4103/sjhs.sjhs_169_19  
Most nations face a range of medical workforce challenges with questions over not only how to overcome public demand for healthcare and maintain a sufficient number of general practitioners but also how to fill shortages in particular hospital specialties and ensure an even distribution of doctors across the population. For both the Gulf Cooperation Council (GCC) and United Kingdom (UK), considering the growth in healthcare expenditure, growing hospital beds, and increasing population burdened by the aging population, the craving for more healthcare professionals can only worsen in the coming future. There is a lack of scientific data comparing the economic aspects of shortage of healthcare professionals in the GCC and UK. These geographically apart regions share a common problem, due to similar etiologies behind them, and both countries are coming closer together on various academic and nonacademic platforms to combat this situation together. We aim to identify various practice methods, decipher the complexities of the healthcare industry of respective local regions in relation to the availability of professionals in their respective economies. There are several recommendations and solutions to bring together the best global practices in each other's jurisdictions to solve the shortage of healthcare professionals.
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ORIGINAL ARTICLES Top

Reliability of two dental age estimation methods in children and comparison with their chronological age p. 133
Yasser R Souror, Harshkant P Gharote
DOI:10.4103/sjhs.sjhs_114_19  
Background: Dental age estimation is being performed since Demirjian proposed dental maturity scores. Subsequently, numerous methods were proposed and were estimated worldwide. Although these methods showed high degrees of reliability, ethnic differences were found to affect the accuracy of the dental age. Objectives: The present study evaluated the relationship between chronological age and dental age using Demirjian and Willems methods in children using digital panoramic radiographs. Materials and Methods: Dental age of 60 digital panoramic radiographs of children (males: 34, females: 26) were calculated using the Demirjian scoring method and Willems scoring method. These age values were compared among themselves as well as with chronological age of the children. Further, the comparison was made by dividing all children in the age ranges of 5-7, 7.1-9, 9.1-11, and 11.1-13 years. The correlations between ages among all parameters were statistically significant except age groups 9.1-11 and 11.1-13 years. Conclusion: A significant correlation was observed between chronological age and dental age estimated by Demirjian and Willems methods. Both methods can be useful in the estimation of chronological age in children.
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Medical students accept virtual patients as a helping tool to achieve their study plan objectives p. 137
Mohammed Ewid
DOI:10.4103/sjhs.sjhs_155_19  
Background: Technical innovation in medical education is a new era that can augment students' problem-solving capabilities. Virtual patients (VPs) have a recognized position in this new era. Research is still ongoing regarding the role of VPs in the learning process of medical students. Aim: The aim of the study was to explore the perception of preclinical and clinical medical students toward VPs in problem-based learning environment. Methods: Thirty-one medical students, 21 preclinical (3rd year) and 10 clinical (4th year) from Sulaiman Al Rajhi Medical College, Saudi Arabia ( first two patches), were enrolled in this cross-sectional study after their acceptance to participate. Necessary orientation was given prior to start by content experts; then, a curriculum-mapped standardized VP case was offered to each group. Following the completion of the VP case, each group had the same standardized validated VP questionnaire to assess their perception and attitude. Results: Respectively, 3rd and 4th year students had the following perceptions regarding VPs: 62% versus 70% considered it a useful learning experience, 48% versus 70% liked practicing it in small groups, and 60% versus 90% recommended incorporating it in upcoming year courses. Eighty percent of the clinical students considered VPs realistic. Clinical and preclinical students' perceptions toward VPs showed no significant difference in all questionnaire items. Conclusion: VPs had a positive impact on medical students and can be implemented in both pre and clinical settings to accomplish their study plan objectives.
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Disturbed sleep and excessive daytime sleepiness in a Saudi population-based sample p. 141
Mohammed D AlAhmari, Khalid R Alshehri
DOI:10.4103/sjhs.sjhs_162_19  
Background: National data on the prevalence of daytime sleepiness and other sleep-related issues are limited for the general Saudi population.Objectives: The aim of this study was to screen a sample of the Saudi population for the prevalence of symptoms of disturbed sleep and excessive daytime sleepiness (EDS), in addition to the sleep duration of the sample.Patients and Methods: A cross-sectional, descriptive population-based sample of n = 1419 participants was randomly recruited from two major public places in the Eastern Province of the Kingdom of Saudi Arabia. The sociodemographic information was collected, and the Epworth Sleepiness Scale (ESS) was used to measure EDS. These and other sleep-related data were assessed after verbal agreements were received from the participants.Results: The total number of participants was n = 1419, with a mean age of 34.1 ± 9.8 years. The response rate was 76.2%, and 917 (65%) were males. The EDS based on the ESS was 53.8% for the sample, with an increasing trend in the higher age groups (11.4 ± 5.8), particularly in the 30–39 years' old age category. Snoring was highly prevalent in the males at 44% versus the females at 21%, and 55% of the participants were smokers. The mean sleep duration was 6.72 ± 1.97 h.Conclusion: EDS was prevalent in particular higher age groups in the general studied population. Snoring was among the highest prevalent sleep-related symptoms with reported shorter sleep duration in the general population. Public awareness of sleep hygiene or psychoeducation and large epidemiological studies are needed to rule out cultural factors and improve the general well-being of the population of the Kingdom of Saudi Arabia.
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Clinical and pathological factors predicting axillary nodal metastasis in breast cancer patients of central Sudan: A single institution experience p. 146
Mohamed Daffalla Awadalla Gismalla, Moawia Mohamed Ali Elhassan, Mohanned Omer Abass
DOI:10.4103/sjhs.sjhs_90_19  
Background: Data on factors predicting axillary lymph node (ALN) metastasis among Sudanese patients with breast cancer are rare. Aim: The aim of this study is to provide baseline information of the clinical and pathological factors predicting ALN metastasis in patients who underwent modified radical mastectomy or breast conserving surgery at Wad-Madani Teaching Hospital, Sudan. Materials and Methods: We performed a prospective study to examine the correlation between ALN status and clinicopathological characteristics of 81 patients with breast cancer. Results: The median age at diagnosis was 47 years (range, 25–85 years). The median number of lymph nodes (LNs) retrieved was 14 (range 2–31). ALNs containing metastases were found in 52 patients (64.2%); more than half of them (n = 30) had three or more positive LNs. Factors associated with lower chance of developing LN metastasis were age more than 60 years, postmenopausal status, smaller tumor size, and tumor that were positive for estrogen receptor and/or progesterone receptor. The number of ALNs retrieved was the only factor which showed statistically significant association with ALNs metastases. Conclusions: Our finding reveals a high incidence of ALN metastasis among patients with breast cancer in Sudan, which is likely due to various factors such as young age at diagnosis and large tumor size as a result of late diagnosis.
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Glucose transporter 1 expression in bladder carcinoma and its association with human epidermal growth factor receptor-2 and Ki-67 p. 151
Sheeja Sainulabdeen, Renu Thambi, Sankar Sundaram, Suresh Bhat
DOI:10.4103/sjhs.sjhs_52_19  
Objective: To assess the expression of glucose transporter 1 (GLUT1) in urothelial carcinomas of urinary bladder and its relationship with human epidermal growth factor receptor-2 (HER2) protein and Ki67 proliferation index. Materials and Methods: Forty-three patients with urothelial carcinoma of bladder were included in the present study. Transurethral resection or cystectomy specimens of tumor were evaluated by histopathology. Grading and staging of these tumors were done followed by immunohistochemistry using antibodies against GLUT1, HER2, and Ki67. Results: Strong expression of GLUT1 score and Ki67 index were seen in higher grades and tumor node metastasis stages of urothelial carcinoma (P < 0.05). In the current study, HER2 overexpression was not significantly associated with tumor grade and stage (P > 0.05). Conclusions: GLUT1 expression showed moderate correlation with HER2 and good correlation with Ki67 index in urothelial carcinoma. Further studies may be needed to assess the role of GLUT1 in prognosis and therapy.
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Is cholecystostomy tube insertion a real bridge for cholecystectomy in acute cholecystitis? A retrospective cohort study p. 157
Abdullah M Alotaibi, Osama Nafea, Ahmad M Deeb, Zeyad Yousef
DOI:10.4103/sjhs.sjhs_74_19  
Background: Percutaneous cholecystostomy (PC) is an alternative treatment in high-risk acute cholecystitis (AC) patients. However, it is debatable whether PC should be considered as a definitive procedure or to be used as a temporizing measure before the definitive cholecystectomy. The aim of this study is to determine if PC is always a bridge for interval cholecystectomy in patients treated at tertiary care center in Saudi Arabia.Materials and Methods: This retrospective cohort study was conducted at a tertiary care center in Saudi Arabia for patients who underwent PC for AC during the period from January 2010 to January 2015. We evaluated the PC tube indications, complications, and outcomes (successful response).Results: A total of 63 patients were included in this study. Around half of the patients were male (54%) with a median age of 69 years. The median hospital length of stay was 17 days, in which 30% of the patients were admitted to the intensive care unit, with a hospital mortality of 25%. The successful response to PC was 79%, with 21% of patients undergoing cholecystectomy.Conclusion: PC is not always a bridge for interval cholecystectomy. However, more studies for patients in whom PC is selected as definite treatment are required.
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Evaluation of critical care providers' knowledge in basic mechanical ventilation management: An opportunity for improvement p. 162
Hajed Marzouk Al-Otaibi
DOI:10.4103/sjhs.sjhs_130_19  
Objectives: This investigation aims to evaluate the knowledge of critical care providers in mechanical ventilation (MV) management and to assess the impact of a 2-day educational package on their knowledge. Materials and Methods: Eighty-nine physicians and nurses attended a 2-day educational course about basic MV management. The basic MV course was conducted in February to June 2017 at Majmaah, Hail, and Arar, Saudi Arabia. Participants were part of a pre-MV course assessment and answered 12 items on a multiple choice questionnaire. After the course, participants repeated the same test (post-MV course assessment). Participants were asked to rate their knowledge of MV management on a scale of 1-10 (before and after the basic MV course). Results: Forty critical care providers (14 physicians and 26 nurses) completed the basic MV course. The participants' clinical experience, on average (±standard deviation), was 5.96 ± 4.6 years. Clinical experience favored physicians. The pre-MV course score for all participants was 4.7 ± 2.29 out of 12, while the post-MV course score was 5.65 ± 2.47. There was a significant statistical difference between pre- and post-MV assessment scores (P = 0.03). Differences between physicians and nurses were significant, on both pre-MV course assessment (P = 0.01) and post-MV course assessment (P = 0.006). There was significant correlation between clinical experience and preassessment scores (r = 0.37; P = 0.03). Conclusion: The present investigation shows that MV management knowledge of critical care providers in hospitals located in small cities is limited. Therefore, it is advisable that critical care providers engaged in continuous professional educational activities related to MV management.
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Nurses' job satisfaction: A multi-center study p. 167
Khalid Abdullah Aljohani
DOI:10.4103/sjhs.sjhs_81_19  
Introduction: Nurses, including expatriates, comprise the majority of Saudi health-care providers. Therefore, the need to measure their satisfaction within the Saudi context is critical for improving patient outcomes and productivity within the health-care system. This study aims to measure nurse job satisfaction in several Ministry of Health (MOH) and Saudi Arabian organizations. Materials and Methods: A multi-center, cross-sectional study design was utilized to recruit nurses from public hospitals and primary health-care centers in five cities across Saudi Arabia. Data were collected from October 1 to November 15, 2016, through an electronic questionnaire. The study instrument was adapted from former MOH surveys. Descriptive and analytical analyses were utilized. Results: A total of 2418 nurses responded with a response rate of 69%. Overall satisfaction level was low to moderate. Only a small portion of the participants demonstrated overall satisfaction in all domains, and living conditions were significantly low. Predictors of satisfaction were studied based on location and job title. Conclusions: The study revealed a low-to-moderate level of job satisfaction with a need to improve nurses' living conditions. Comparisons among the study locations revealed areas in need of improvement. Further studies are needed to explore methods through which to enact these improvements.
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Diverse clinical manifestations of empty sella syndrome: An imaging based study p. 172
Nkem Nnenna Nwafor, Adenike Olayemi Akhigbe
DOI:10.4103/sjhs.sjhs_122_19  
Background: Empty sella is an imaging finding previously thought to be of no clinical consequence in our environment. It has been classified into primary empty sella which is related to increased intracranial pressure and secondary empty sella which is considered a sequel of previous pituitary lesions. Studies have documented various clinical manifestations which we are beginning to see in our environment. Methods: This is a retrospective study done over a three-year period between May 2016- May 2019 in a private radiodiagnostic center. The subjects presented for brain magnetic resonance imaging for diverse, chronic clinical symptoms such as chronic headaches, visual disturbances and galactorrhoea and empty sella was found on imaging. The essence of the imaging was to demonstrate or to rule out a structural cause for the clinical symptoms of the subjects. Results: Eight female subjects between the ages of 34-56 years with a mean age of 45.0 ± 11.0 years presented with chronic symptoms. The most common symptoms were headaches (n = 8, 100%), visual disturbances (n = 3, 37.5%), chronic fatigue (n = 3, 37.5%), galactorrhea (n = 2, 25%), secondary infertility (n = 2, 25%), weight gain (n = 2, 25%) and psychotic symptoms (n = 2, 25%). Imaging finding showed empty sella in all subjects. One subject had features of chronic venous infarct. Conclusion: Empty sella syndrome presents in complex ways. Most of the symptoms can be explained by increased pressure on structures around the sella which control various organs in the body. In a resource poor setting like ours, empty sella should be considered in obese female subjects with chronic headaches.
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Prescribing practices of antibiotics and analgesics in orthopedic surgery in two teaching hospitals in pakistan p. 176
Zakir Khan, Naveed Ahmed, Shaista Zafar, Asim ur. Rehman, Faiz Ullah Khan, Yusuf Karatas
DOI:10.4103/sjhs.sjhs_108_19  
Background: A judicious utilization of antibiotic prophylaxis and postoperative analgesics are an effective strategy to prevent surgical site infections and pain, respectively. Aims: The aim of this study was to assess prescription practices and guidelines adherence of antibiotics and analgesics in total knee replacement (TKR) surgery. Setting and Design: A cohort observational pilot study was conducted for a period of 2 months at two tertiary care teaching hospital (government hospital = GH and private hospital = PH) in Islamabad, Pakistan. Subjects and Methods: All the individuals aged ≥18 who underwent TKR surgery with no previous surgery and infection (n = 300) were included during the study period. The patient medication profile was analyzed through various indicators. International evidence-based guidelines were used as a reference to analyze current treatment practices. Statistical Analysis Used: Descriptive statistics such as frequencies, percentages, averages, standard deviation, and Chi-square test was used for interpretation of data in SPSS V-22.0. Results: Preoperative prophylactic antibiotics were prescribed in 94% (n = 283) cases. Of these, 61.5% adhered according to guidelines with respect to correct choice, 64.6% for timing, and 100% for the route (optimal value 100%). The prescribing behavior with respect to antibiotic choice and timing was different among GH and PH hospitals (P = 0.001). Cefazolin was the most commonly prescribed preoperative and postoperative antibiotic, followed by cefuroxime. With respect to analgesics, paracetamol and tramadol were frequently used in TKR patients. One hundred and seventy six (58.6%) patients received analgesics according to the guidlines recommendations, and 7.8% (n = 23) received more than one analgesic in their postoperative prescription. Conclusion: The low compliance rate with guidelines was observed. The choice and timing of antibiotic, selection of analgesics, and its multiple usage were main identified problems.
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Risk factors, pattern of presentation, methods of diagnosis, and results of treatment of acute portal vein thrombosis: A multicenter study p. 182
Mohamed Salem Al Saeed, Bilal O Al-Jiffry, Alaa Younes, Samir Badr, Tamer Abdel-Rahman, Mohamed Hatem, Mahmoud El-Meteini
DOI:10.4103/sjhs.sjhs_77_19  
Background and Aim of the Work: Portal vein thrombosis (PVT) is a serious condition; however, the outcome may be improved by early recognition and prompt management. The aim of this multicenter retrospective study is to evaluate the underlying risk factors, pattern of presentation, methods of diagnosis, and results of treatment of cases of acute/recent PVT in Taif tertiary hospitals.Methods: In this chart review and database study, 103 patients met the inclusion criteria. Data extracted from the medical records were analyzed for underlying risk factors, pattern of presentation, diagnostic tools, and results of treatment.Results: The underlying causes of PVT were cirrhosis (46.6%) and noncirrhotic causes (43.7%), and no obvious cause was recorded in 9.7% of cases. In 9.7% of the patients, PVT progressed to mesenteric venous occlusion. The diagnosis was established by initial duplex ultrasound scan or/and contrast-enhanced computed tomography scan in 97.1% of patients. Anticoagulation was started for all patients after established diagnosis except in patients with gastrointestinal bleeding. In all patients with mesenteric venous occlusion, infarcted segments were found and resected during abdominal exploration. The recorded overall mortality during follow-up was 51.5%, and it was significantly higher in cirrhotic than in noncirrhotic patients (P < 0.05).Conclusions: Cirrhosis is the main underlying cause of PVT in Taif, Saudi Arabia. Most of the findings in this study about epidemiological and risk factors were quite different from that of other global findings. More studies are required to assess the actual magnitude of PVT in Taif and other Saudi Arabia provinces.
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CASE REPORTS Top

A clinicopathologic discussion on a case of asymptomatic swelling on the ventral tongue p. 191
Sunila Thomas, Vivek Velayudhannair, Jincy Thomas, Saranya Balachandran Lekha
DOI:10.4103/sjhs.sjhs_128_19  
The tongue is a complex structure composed of muscles, nerve fibers, blood vessels, salivary glands, etc. A swelling on the ventral tongue can arise from any of these tissues. We report a case and clinicopathologic discussion of asymptomatic swelling on the ventral surface of the tongue in a 13-year-old female patient under orthodontic treatment, diagnosed as extravasation mucocele. Oral mucocele is a benign minor salivary gland lesion which occurs due to trauma or obstruction. Extravasation mucocele seen in this case resembles mucocele developing from the glands of Blandin and Nuhn. This article emphasizes the importance of clinicopathological correlation in diagnosing common lesions in uncommon locations.
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A torn longitudinal vaginal septum in a multiparous woman causing sexual dissatisfaction p. 194
Muhammad Baffah Aminu, Abubakar Muhammad Shehu, Lamaran Makama Dattijo, Kingsley Oranuka
DOI:10.4103/sjhs.sjhs_116_19  
Longitudinal vaginal septum is one of the Mullerian abnormalities affecting the lower genital tract. It is a rare but frequent cause of dyspareunia in early adult life and occurs as a result of incomplete fusion of the lower part of the two Mullerian ducts or failure of canalization of the vaginal plate. We report the case of a multipara who had a fleshy mass protruding from the vagina and sexual dissatisfaction with no associated symptoms of uterovaginal prolapse. She had examination under anesthesia and simple surgical excision, following which she had relief of her symptoms. This is a unique case occurring in a multipara (para 4) that went unnoticed until after the fourth childbirth. A careful evaluation of all clients with dyspareunia or sexual dissatisfaction after delivery should be the watchword.
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